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OBJECTIVE A carefully selected subset of civilian cranial gunshot wound (CGSW) patients may be treated with simple wound closure (SWC) as a proactive therapy, but the appropriate clinical scenario for using this strategy is unknown. The aim of this study was to compare SWC and surgery patients in terms of their neurological outcomes and complications, including infections, seizures, and reoperations. METHODS This was a single-center, retrospective review of the prospectively maintained institutional traumatic brain injury and trauma registries. Included were adults who sustained an acute CGSW defined as suspected or confirmed dural penetration. Excluded were nonfirearm penetrating injuries, patients with an initial Glasgow Coma Scale (GCS) score of 3, patients with an initial GCS score of 4 and nonreactive pupils, and patients who died within 48 hours of presentation. RESULTS A total of 67 patients were included; 17 (25.4%) were treated with SWC and 50 (74.6%) were treated with surgery. The SWC group had a lower incidence of radiographic mass effect (3/17 [17.6%] SWC vs 31/50 [62%] surgery; absolute difference 44.4, 95% CI −71.9 to 16.8; p = 0.002) and lower incidence of involvement of the frontal sinus (0/17 [0%] SWC vs 14/50 [28%] surgery; absolute difference 28, 95% CI −50.4 to 5.6; p = 0.01). There were no differences in the frequency of Glasgow Outcome Scale–Extended scores ≥ 5 between the SWC and surgery groups at 30 days (4/11 [36.4%] SWC vs 12/35 [34.3%] surgery; OR 1.1, 95% CI 0.3–4.5; p > 0.99), 60 days (2/7 [28.6%] SWC vs 8/26 [30.8%] surgery; OR 0.9, 95% CI 0.3–3.4; p > 0.99), and 90 days (3/8 [37.5%] SWC vs 12/26 [46.2%] surgery; OR 0.7, 95% CI 0.1–3.6; p > 0.99). There were no differences in the incidence of infections (1/17 [5.9%] SWC vs 6/50 [12%] surgery; OR 0.5, 95% CI 0.1–4.1; p = 0.67), CSF fistulas (2/11 [11.6%] SWC vs 3/50 [6%] surgery; OR 2.1, 95% CI 0.3–13.7; p = 0.60), seizures (3/17 [17.6%] SWC vs 9/50 [18%] surgery; OR 1, 95% CI 0.2–4.1; p > 0.99), and reoperations (3/17 [17.6%] SWC vs 4/50 [8%] surgery; OR 2.5, 95% CI 0.5–12.4; p = 0.36) between the SWC and surgery groups. CONCLUSIONS There were important clinically relevant differences between the SWC and surgery groups. SWC can be considered a safe and efficacious proactive therapy in a carefully selected subset of civilian CGSW patients.

The optimal management of asymptomatic, presumed WHO grade I meningiomas remains controversial.To define the safety and efficacy of stereotactic radiosurgery (SRS) compared with active surveillance for the management of patients with asymptomatic parafalcine/parasagittal (PFPS) meningiomas.Data from SRS-treated patients from 14 centers and patients managed conservatively for an asymptomatic, PFPS meningioma were compared. Local tumor control rate and new neurological deficits development were evaluated in the active surveillance and the SRS-treated cohorts.There were 173 SRS-treated patients and 98 patients managed conservatively in the unmatched cohorts. After matching for patient age and tumor volume, there were 98 patients in each cohort. The median radiological follow-up period was 43 months for the SRS cohort and 36 months for the active surveillance cohort (P = .04). The median clinical follow-up for the SRS and active surveillance cohorts were 44 and 36 months, respectively. Meningioma control was noted in all SRS-treated patients and in 61.2% of patients managed with active surveillance (P.001). SRS-related neurological deficits occurred in 3.1% of the patients (n = 3), which were all transient. In the active surveillance cohort, 2% of patients (n = 2) developed neurological symptoms because of tumor progression (P = 1.0), resulting in death of 1 patient (1%).Up-front SRS affords superior radiological PFPS meningioma control as compared with active surveillance and may lower the risk of meningioma-related permanent neurological deficit and/or death.

Objective: the optimal management of asymptomatic, skull-based meningiomas is not well defined. The aim of this study is to compare the imaging and clinical outcomes of patients with asymptomatic, skull-based meningiomas managed either with upfront stereotactic radiosurgery (SRS) or active surveillance. Methods: this retrospective, multicenter study involved patients with asymptomatic, skull-based meningiomas. The study end-points included local tumor control and the development of new neurological deficits attributable to the tumor. Factors associated with tumor progression and neurological morbidity were also analyzed. Results: the combined unmatched cohort included 417 patients. Following propensity score matching for age, tumor volume, and follow-up 110 patients remained in each cohort. Tumor control was achieved in 98.2% and 61.8% of the SRS and active surveillance cohorts, respectively. SRS was associated with superior local tumor control (p < 0.001, HR = 0.01, 95% CI = 0.002-0.13) compared to active surveillance. Three patients (2.7%) in the SRS cohort and six (5.5%) in the active surveillance cohort exhibited neurological deterioration. One (0.9%) patient in the SRS-treated and 11 (10%) patients in the active surveillance cohort required surgical management of their meningioma during follow-up. Conclusions: SRS is associated with superior local control of asymptomatic, skull-based meningiomas as compared to active surveillance and does so with low morbidity rates. SRS should be offered as an alternative to active surveillance as the initial management of asymptomatic skull base meningiomas. Active surveillance policies do not currently specify the optimal time to intervention when meningioma growth is noted. Our results indicate that if active surveillance is the initial management of choice, SRS should be recommended when radiologic tumor progression is noted and prior to clinical progression., NA

Determining the appropriate surgical indications for obtunded octogenarians with traumatic acute subdural hematoma (aSDH) has been challenging. We sought to determine which easily available data would be useful adjuncts to assist in early and quick decision-making.We performed a single-center, retrospective review of patients aged ≥80 years with confirmed traumatic aSDH who had undergone emergent surgery. The clinical measurements included the Karnofsky performance scale score, Charlson comorbidity index, Glasgow coma scale (GCS), and abbreviated injury score. The radiographic measurements included the Rotterdam computed tomography score, aSDH thickness, midline shift, and optic nerve sheath diameter (ONSD). The neurologic outcomes were defined using the extended Glasgow outcome scale-extended (GOS-E) at hospital discharge and 3-month follow-up. The Pearson correlation coefficient was used to compare the ONSD with all clinical, radiographic, and outcome variables. Multivariate logistic regression was used to assess the relationship between the discharge and 3-month GOS-E scores between all clinical and radiographic variables.A total of 17 patients met the inclusion criteria. The mean age was 82.5 ± 1.6 years (range, 80-85 years), and the mean GCS score was 11.2 ± 4.1 (range, 4-15). The mean discharge and 3-month GOS-E scores were 3.4 ± 2.6 (range, 1-8) and 2.3 ± 2.1 (range, 1-7), respectively. We found significant negative correlations between the ONSD and the GCS score (r = -0.62; P0.01) and the ONSD and discharge GOS-E score (r = -0.49; P = 0.05). Multivariate analysis revealed a significant association between the abbreviated injury score and the discharge GOS-E score (P = 0.05).Octogenarians sustaining aSDH and requiring emergent surgery have poor outcomes. More data are needed to determine whether the ONSD can be a useful adjunct tool to predict the efficacy of emergent surgery.

Background The optimal management of patients with incidental meningiomas remains unclear. The aim of this study was to characterize the radiologic and neurological outcomes of expectant and stereotactic radiosurgery (SRS) management of asymptomatic meningioma patients. Methods Using data from 14 centers across 10 countries, the study compares SRS outcomes to active surveillance of asymptomatic meningiomas. Local tumor control of asymptomatic meningiomas and development of new neurological deficits attributable to the tumor were evaluated in the SRS and conservatively managed groups. Results In the unmatched cohorts, 727 meningioma patients underwent SRS and were followed for a mean of 57.2 months. In the conservatively managed cohort, 388 patients were followed for a mean of 43.5 months. Tumor control was 99.0% of SRS and 64.2% of conservatively managed patients (P < .001; OR 56.860 [95% CI 26.253-123.150]). New neurological deficits were 2.5% in the SRS and 2.8% of conservatively managed patients (P = .764; OR 0.890 [95% CI 0.416-1.904]). After 1:1 propensity matching for patient age, tumor volume, location, and imaging follow-up, tumor control in the SRS and conservatively managed cohorts was 99.4% and 62.1%, respectively (P < .001; OR 94.461 [95% CI 23.082-386.568]). In matched cohorts, new neurological deficits were noted in 2.3% of SRS-treated and 3.2% of conservatively managed patients (P = .475; OR 0.700 [95% CI 0.263-1.863]). Conclusions SRS affords superior radiologic tumor control compared to active surveillance without increasing the risk of neurological deficits in asymptomatic meningioma patients. While SRS and active surveillance are reasonable options, SRS appears to alter the natural history of asymptomatic meningiomas including tumor progression in the majority of patients treated.

Gamma knife radiosurgery (GKRS) is often performed to treat brain metastases (BrMs). Widely referenced guidelines have suggested post-treatment imaging studies at 3-month intervals. However, clinicians frequently obtain magnetic resonance imaging (MRI) studies at3 months after GKRS.We performed a retrospective medical record review study to assess the utility of early (3 months) MRI after GKRS in patients with BrMs.A total of 415 GKRS procedures were performed. For 325 patients, early MRI studies were obtained. A total of 31 patients had new or worsened neurological symptoms. The early MRI studies showed adverse findings in 25 patients (78%), which in 23 (72%) had resulted in a change in treatment. For 294 patients, no new or worsened neurological symptoms were found on early MRI studies. Of these 294 patients, 86 (29%) had ≥1 adverse finding on MRI, and 60 (20%) had a change in management as a result. However, no rapidly growing tumors or other emergent adverse findings were seen.Early MRI (within 3 months) after post GKRS will frequently show adverse findings even in asymptomatic patients, more often in patients aged65 years and patients with multiple treated BrMs. However, according to the nature of the adverse findings observed in our retrospective study, it is unlikely that the clinical outcomes would have been affected if the post-GKRS MRI studies had been deferred to 3 months after treatment. Our data support deferring post-GKRS MRI to 3 months after treatment in the absence of new neurological signs or symptoms.

Meningioma, a type of brain tumor, is a common incidental finding on brain imaging. The best management approach for patients with an incidental meningioma remains unclear. This retrospective multi-center study investigated the outcomes of patients with an incidental meningioma in a frontobasal location, who were managed with active surveillance (n = 28) compared to stereotactic radiosurgery (SRS) (n = 84). Within 5 years of follow-up, SRS improved the radiological control of incidental frontobasal meningiomas (0% vs. 52%), but no symptoms occurred in either group. In the active surveillance cohort, 12% underwent an intervention for tumor growth. The findings of this study provide information to enable shared decision making between clinicians and patients with incidental frontobasal meningiomas. Meningioma is a common incidental finding, and clinical course varies based on anatomical location. The aim of this sub-analysis of the IMPASSE study was to compare the outcomes of patients with an incidental frontobasal meningioma who underwent active surveillance to those who underwent upfront stereotactic radiosurgery (SRS). Data were retrospectively collected from 14 centres. The active surveillance (n = 28) and SRS (n = 84) cohorts were compared unmatched and matched for age, sex, and duration of follow-up (n = 25 each). The study endpoints included tumor progression, new symptom development, and need for further intervention. Tumor progression occurred in 52.0% and 0% of the matched active surveillance and SRS cohorts, respectively (p < 0.001). Five patients (6.0%) treated with SRS developed treatment related symptoms compared to none in the active monitoring cohort (p = 0.329). No patients in the matched cohorts developed symptoms attributable to treatment. Three patients managed with active surveillance (10.7%, unmatched; 12.0%, matched) underwent an intervention for tumor growth with no persistent side effects after treatment. No patients subject to SRS underwent further treatment. Active monitoring and SRS confer a similarly low risk of symptom development. Upfront treatment with SRS improves imaging-defined tumor control. Active surveillance and SRS are acceptable treatment options for incidental frontobasal meningioma., NA

BACKGROUND Primary decompressive craniectomy (DC) is commonly performed for patients with traumatic brain injury (TBI). Some, but not all patients, will benefit from invasive monitoring of intracranial pressure (ICP) after surgery. We intended to identify risk factors for elevated ICP after primary DC to treat TBI. METHODS A retrospective chart review study identified all patients at our institution who underwent primary DC for TBI during the study period and who had ICP monitors placed at the time of surgery. Various preoperative and intraoperative variables were assessed for correlation with the presence of postoperative elevated ICP. RESULTS Postoperative elevated ICP occurred in 36% of patients after DC. In univariate analysis, Glasgow Coma Scale

The optimal management of asymptomatic, petroclival meningiomas remains incompletely defined. The purpose of this study was to evaluate the safety and efficacy of upfront stereotactic radiosurgery (SRS) for patients with asymptomatic, petroclival region meningiomas. This retrospective, international, multicenter study involved patients treated with SRS for an asymptomatic, petroclival region meningioma. Study endpoints included local tumor control rate, procedural complications, and the emergence of new neurological deficits. There were 72 patients (22 males, mean age 59.53 years (SD ± 11.9)) with an asymptomatic meningioma located in the petroclival region who were treated with upfront SRS. Mean margin dose and maximum dose were 13.26 (SD ± 2.72) Gy and 26.14 (SD ± 6.75) Gy respectively. Median radiological and clinical follow-up periods post-SRS were 52.5 (IQR 61.75) and 47.5 months (IQR 69.75) respectively. At last follow-up, tumor control was achieved in all patients. SRS-related complications occurred in 6 (8.33%) patients, with 3 of them (4.17%) exhibiting new neurological deficits. Upfront SRS for asymptomatic, petroclival region meningiomas affords excellent local tumor control and does so with a relatively low risk of SRS-related complications. SRS can be considered at diagnosis of an asymptomatic petroclival region meningioma. If active surveillance is initially chosen, SRS should be recommended when growth is noted during radiological follow-up.

Neurologic symptoms from leukemic infiltration of the central nervous system are an oncologic emergency, and expeditious treatment is required to preserve function. We report the case of a 44-year-old patient with relapsed acute myeloid leukemia (AML) who developed sub-acute cranial neuropathies refractory to treatment with intrathecal (IT) chemotherapy. The patient was therefore treated with an emergent course of whole-brain radiotherapy, resulting in immediate improvement and subsequent resolution of cranial neuropathies. This case illustrates that while central nervous system involvement by AML is rare, radiotherapy remains an effective modality to avoid long-term morbidity in patients failing to respond to systemic or IT chemotherapy.

PURPOSE/OBJECTIVE(S) Patients undergoing stereotactic radiosurgery (SRS) for brain metastases often relapse and require additional radiation. Due to the paucity of data, the decision to offer salvage re-irradiation with whole brain radiation therapy (WBRT) versus SRS is made on an individual basis. Our objective is to determine the clinical and demographic factors associated with SRS versus WBRT for salvage of first intracranial failure (ICF), i.e., local and/or locoregional failures. MATERIALS/METHODS We identified a cohort of 374 consecutive patients with brain metastases treated with SRS in the definitive or postoperative setting, at a single institution, from August 2014 to September 2019. Eligible patients received subsequent salvage radiation at our institution with WBRT or SRS at least one month after initial SRS. Clinical and demographic characteristics were retrospectively recorded. Univariate (UVA) and multivariate analyses (MVA) were performed to determine if there was a significant correlation between these factors and the use of salvage SRS versus WBRT. Odds ratios (ORs) and corresponding P-values were estimated from logistic regression model. A survival analysis was also performed to assess the impact of these factors on survival. All tests were two sided and P-value of 70, Stable/absent systemic disease, and receipt of salvage SRS. CONCLUSION The strongest factor associated with selection of salvage WBRT vs. SRS for ICF following initial SRS is local progression. There was also found to be a significant disparity in the form of decreased salvage SRS for male patients that remained significant when controlling for other disease and socioeconomic factors. Possible etiologies of this difference could be provider or patient driven but warrant further exploration. In this cohort, salvage SRS was associated with a statistically significant improvement in OS, however, this may also represent a selection bias. AUTHOR DISCLOSURE Y.S. Soni: None. B.J. Rich: None. D. Kwon: None. W. Zhao: None. D.L. John: None. C.S. Seldon: None. C. Benjamin: None. R. Benveniste: None. R.J. Komotar: None. P. Prieto: None. M. De La Fuente: None. G. Azzam: None. E.A. Mellon: None. T. Diwanji: None.

Purpose/Objective(s) Although patients with brain metastasis treated with stereotactic radiosurgery (SRS) in the definitive or post-operative setting have high rates of local control, surveillance imaging is necessary to assess for central nervous system (CNS) recurrence. Guidelines recommend magnetic resonance imaging (MRI) of the brain every three months for surveillance in asymptomatic patients post-SRS. However, optimal frequency and duration of surveillance imaging in long-term survivors is unknown. Our objective is to define the yield and cost of surveillance MRIs in long-term (> 1 year) survivors following SRS. Materials/Methods We identified a cohort of patients with brain metastases treated with SRS in the definitive or postoperative setting at a single institution from 8/2014 to 9/2019. Eligible patients had at least one-year of follow-up with absence of CNS disease failure up to and including the first MRI of the brain after 12 months from SRS. Each post-treatment MRI of the brain was assessed for disease progression or new lesions. CNS disease-free survival was time from SRS to last follow-up, death or CNS failure. Delay to diagnosis and cost per patient were estimated using hypothetical MRI schedules of 2, 3, 4 and 6 months from 1-year post-treatment while CNS disease-free. Delay to diagnosis was calculated as time from actual CNS progression to hypothetical imaging date. Medicare reimbursement median cost of $498 per MRI brain with and without contrast was used for this analysis. Results A total of 373 patients treated with SRS for brain metastasis were identified at our institution. 61 patients met eligibility criteria for inclusion in this study (median follow-up 2.50 years, median age at treatment 60 years). The median CNS disease-free survival in this population was 2.37 years from date of SRS. 15 patients (24.6%) had CNS progression at median time of 2.26 years. Of the 15 patients, 3 patients were symptomatic at recurrence. Median frequency of MRI after one year post SRS was 5.9 months. Per patient, $1156 was spent annually on MRIs of the brain after 12 months with average annual yield of 17.0%. The cost per diagnosis of CNS progression was $6806. A 2-month, 3-month, 4-month and 6-month MRI schedule had a respective estimated delay to diagnosis of 0.69 months, 1.13 months, 1.44 months and 3.19 months. The respective mean total cost of each MRI schedule per patient from one-year post-treatment while CNS disease-free was $4662, $3053, $2229 and $1380. Conclusion Patients with metastatic disease to the brain treated definitively or postoperatively with SRS without evidence of CNS recurrence at one year have a low rate of CNS failure and relatively good prognosis. Based strictly on limiting delay of diagnosis, a 2-month MRI Brain schedule is optimal in this population, albeit with a relatively small increase in financial cost over the patient's lifespan. We propose a multi-institutional study of long-term survivors with brain metastasis to strengthen these findings. Author Disclosure B.J. Rich: None. D. Kwon: None. Y.S. Soni: None. D.L. John: None. J.B. Bell: None. G. Azzam: None. E.A. Mellon: None. R. Yechieli: Support and guide school in strategic and management related matters; Toras Chaim Toras Emes, Miami FL.C. Benjamin: None. R. Benveniste: None. R.J. Komotar: None. M. Ivan: None. J. Morcos: None. T. Diwanji: None.

Background Delayed subdural fluid collections can occur after Ommaya reservoir placement and can cause neurological symptoms and interfere with treatment. We performed a retrospective chart review in order to study risk factors for delayed subdural fluid collections and clinical outcomes. Methods Retrospective chart review was performed for patients undergoing ommaya reservoir placement between 2010-2019 at our institution. Results Out of 53 patients who had Ommaya reservoir placement during the study period, 11 developed delayed subdural fluid collections (21%). HIV infection was the only statistically significant risk factor (p=0.001, Fisher exact test). Thrombocytopenia, ventricle size, use of the reservoir, and suboptimal catheter placement were not associated with development of delayed subdural fluid collections. 2 patients, both HIV positive, required surgical evacuation. Conclusions Delayed subdural fluid collections occur in a significant minority of patients after Ommaya reservoir placement, and some patients require surgical intervention. HIV infection is associated with a higher risk of development of delayed subdural fluid collections. This patient subpopulation may benefit from closer monitoring or adjustment of management protocols.

Patients who present with traumatic brain injury (TBI) combined with blunt cerebrovascular injuries (BCVI) are difficult to manage, in part because treatment for each entity may exacerbate the other. It is necessary to develop a treatment paradigm that ensures maximum benefit while mitigating the opposing risks. A cohort of 150 patients from 2015 to present, with either internal carotid artery (ICA) and/or vertebral artery (VA) dissections or pseudoaneurysms, was cross-referenced with those who had sustained TBI. Of the 38 patients identified with both TBI and BCVI, 25 suffered ICA injuries, 10 had VA injuries and 3 had combined ICA/VA injuries. Unilateral BCVI occurred in 30 patients, while 8 had bilateral BCVI. Two patients required surgical intervention for TBI, and 5 patients required endovascular intervention for BCVI. Positive emboli detection studies (EDS) on transcranial dopplers (TCD) were demonstrated in 19 patients, with 9 patients having radiographic evidence of stroke. Anti-platelet therapy was initiated in 32 patients, and anti-coagulation in 10 patients, without new or worsening intracranial hemorrhages (ICH). Overall, 76% of patients were able to be discharged home or to rehabilitation, with good recovery demonstrated in 73% of the patients who had appropriate follow-up. In the setting of concurrent TBI and BCVI, use of anti-platelet/coagulation to prevent stroke can be safe if monitored closely. Here we describe a treatment paradigm which weighs the risk and benefits of therapies based on severity of ICH and stroke prevention, which tended to result in good disposition and recovery.

Normal pressure hydrocephalus (NPH) is generally treated with ventriculoperitoneal shunts (VPS), with improved symptoms in the majority of patients. We performed a retrospective chart review study in order to describe patterns of, and risk factors for, delayed symptom progression after initially successful VPS placement. 69 consecutive patients underwent VPS placement for NPH, and were followed for a minimum of 12 months postoperatively. 55 patients (80%) had objective improvement in their NPH symptoms after surgery. Of these, 27 patients (49%) developed delayed deterioration of at least one of their NPH symptoms, at a mean of 28.3 months postoperatively (range, 3–77). 1 of the 27 patients was found to have shunt malfunction; 19 had specific clinical or imaging evidence of shunt function. 6/19 patients had transient improvement in their symptoms (lasting 30 days or more) after adjustment of their programmable shunt valves (32%), although symptoms in all of these patients later worsened. During a mean follow up period of 44.4 months (range, 15–87), 12 patients (44%) received other neurological diagnoses felt to at least partially explain their symptoms. Increased patient age was associated with likelihood of delayed symptom progression. We conclude that delayed symptom progression is common after VPS placement for NPH, including after initial symptom improvement; that symptom progression can often be temporarily palliated by shunt valve pressure adjustment; and that older patients are more likely to experience delayed symptom progression. We suggest that patients and their families be counselled accordingly before surgery.

Background Our understanding of radiation induced meningiomas (RIM) is limited. It has been suggested that RIM harbor more aggressive cellular pathology and must be observed vigilantly. However, the actual recurrence rates of RIM compared to the sporadic meningiomas has yet to be defined. Objective We employ a single center case-control study to retrospectively assess recurrence rates between RIM (n = 12) and sporadic meningiomas (n = 118). Methods The criteria for the RIM group included the following: 1) History of intracranial clinical-dose radiation 2) Initial pathology other than meningioma, 3) Radiation administered greater than 5 years prior to meningioma onset. Recurrence rates, extent of resection and outcomes were analyzed. Results There was a significant difference in recurrence rates between the RIM group and sporadic meningioma: 50% vs. 5% respectively, p = 0.004. There was no significant difference in race, preoperative tumor volume, extent of resection, Ki67, or age between the two groups. Multivariate analysis demonstrated that size (OR 0.95 95%CI (0.92–0.99)), extent of resection (OR 1.08 95%CI (1.01–1.14)), WHO grade (OR 160.24 95% CI (6.32–74509)) and history of previous radiation (OR 1.28 95%CI (1.01–1.62)) were independent risk factors for recurrence. RIM patients had significantly higher proportion of atypical or malignant histology compared to sporadic patients (p Conclusion RIM patients may have a higher predisposition for tumor recurrence than patients with sporadic RIM. The use of Ki67 indices may help identify patients with a higher risk of tumor recurrence. Prospective studies focusing on newly diagnosed patients with RIM may help identify an optimal surveillance and treatment plan.

Background Because less-invasive techniques can obviate the need for brain biopsy in the diagnosis of primary central nervous system lymphoma (PCNSL), it is common practice to wait for a thorough initial work-up, which may delay treatment. We conducted a systematic review and reviewed our own series of patients to define the role of LP and early brain biopsy in the diagnosis of PCNSL. Methods Our study was divided into 2 main sections: 1) systematic review assessing the sensitivity of cerebrospinal fluid (CSF) analysis on the diagnosis of PCNSL, and 2) a retrospective, single-center patient series assessing the diagnostic accuracy and safety of early biopsy in immunocompetent PCNSL patients treated at our institution from 2012 to 2018. Results Our systematic review identified 1481 patients with PCNSL. A preoperative LP obviated surgery in 7.4% of cases. Brain biopsy was the preferred method of diagnosis in 95% of patients followed by CSF (3.1%). In our institutional series, brain biopsy was diagnostic in 92.3% of cases (24/26) with 2 cases that required a second procedure for diagnosis. Perioperative morbidity was noted in 7.6% of cases (n = 2) due to hemorrhages after stereotactic brain biopsy that improved at follow-up. Conclusions The diagnostic yield of CSF analyses for PCNSL in immunocompetent patients remains exceedingly low. Our institutional series demonstrates that early biopsy for PCNSL is safe and accurate, and may avert protracted work-ups. We conclude that performing an early brain biopsy in a suspected case of PCNSL is a valid, safe option to minimize diagnostic delay.

Since the beginning of the 1990s, sea level is routinely measured using high-precision satellite altimetry. Over the past \(\sim \)25 years, several groups worldwide involved in processing the satellite altimetry data regularly provide updates of sea level time series at global and regional scales. Here we present an ongoing effort supported by the European Space Agency (ESA) Climate Change Initiative Programme for improving the altimetry-based sea level products. Two main objectives characterize this enterprise: (1) to make use of ESA missions (ERS-1 and 2 and Envisat) in addition to the so-called ‘reference’ missions like TOPEX/Poseidon and the Jason series in the computation of the sea level time series, and (2) to improve all processing steps in order to meet the Global Climate Observing System (GCOS) accuracy requirements defined for a set of 50 Essential Climate Variables, sea level being one of them. We show that improved geophysical corrections, dedicated processing algorithms, reduction of instrumental bias and drifts, and careful linkage between missions led to improved sea level products. Regarding the long-term trend, the new global mean sea level record accuracy now approaches the GCOS requirements (of \(\sim \)0.3 mm/year). Regional trend uncertainty has been reduced by a factor of \(\sim \)2, but orbital and wet tropospheric corrections errors still prevent fully reaching the GCOS accuracy requirement. Similarly at the interannual time scale, the global mean sea level still displays 2–4 mm errors that are not yet fully understood. The recent launch of new altimetry missions (Sentinel-3, Jason-3) and the inclusion of data from currently flying missions (e.g., CryoSat, SARAL/AltiKa) may provide further improvements to this important climate record.

Objective We sought to determine whether a set of simple criteria can identify patients in the neuroscience intensive care unit (NICU) at high risk of poor outcome and delivery of nonbeneficial care early in the course of their illness. Secondarily, factors affecting limitation of care protocols were assessed. Methods We prospectively identified patients who were admitted to the NICU with partial loss of brainstem reflexes persisting for >24 hours due to an intrinsic lesion of the brain (trauma, stroke, hemorrhage, etc.). Results The study included 102 patients. Seventy-two of them died after a mean of 16 days (median: 8 days), and 23 remained comatose, locked-in, or in a vegetative state. Four were conscious and following commands, while 3 were minimally conscious, episodically obeying simple commands. Three out of 4 conscious patients were young males with traumatic brain injuries. Patients who remained full code spent a mean of 22.2 days in the NICU, compared with 10.4 for those who had withdrawal of care (P = 0.022) and 11.9 for patients who received a do-not-resuscitate order (P = 0.045). Time to death did not differ significantly between the groups. Overall, institution of various limitations of care protocols correlated positively with older age (odds ratio [OR] = 1.07, P = 0.0008), being treated on the neurology service (OR = 4.4, P = 0.043), and having health insurance (OR = 5.4, P = 0.03). Conclusions We identified simple criteria that can be used to identify patients in the NICU setting for whom continued aggressive care is likely nonbeneficial. Our analysis revealed demographic, social, and economic factors correlating with proxies' willingness to consider limitation of care.

Object The aim of this study is to identify pre-operative clinical and/or radiological predictors of clinical failure of decompressive hemicraniectomy (DH) in the setting of malignant hemispheric infarction. These predictors could guide the decision for adjunctive internal brain decompression (e.g. strokectomy) at the time of the initial DH. Methods Retrospective chart review of all patients with malignant hemispheric infarction who underwent DH at our institution, from November 2008 to January 2013. Demographics, pre- and post-operative clinical characteristics and neuroimaging data were reviewed. The surgical outcome after DH was evaluated and clinical failure was defined as follows: lack of post-operative resolution of basal cistern effacement, and/or failure to achieve a post-operative decrease in midline shift by at least 50%, and/or post-operative neurological deterioration felt to be due to persistent mass effect, with or without a second, salvage operation (strokectomy). Results Out of 26 patients included in the study, 7 were considered to have clinical failure of their DH. Preoperative clinical and imaging variables were similar in the two groups, except that the presence of a nonreactive pupil immediately before surgery was associated clinical failure of the DH (p = 0.0015). Patients in the clinical failure group had a lower postoperative GCS motor score and a strong but not statistically significant trend towards less favorable functional outcome (GOS 1–3). Conclusions The presence of a nonreactive pupil before surgery is associated with clinical failure of DH, and should be taken into account when deciding whether to perform strokectomy at the time of DH.

The backscatters power single-look waveform recorded by a synthetic aperture radar altimeter is approximated in a closed-form model. The model, being expressed in terms of parameterless functions, allows for efficient computation of the waveform and a clear understanding of how the various sea state and instrument parameters affect the waveform.

This chapter describes both the improvements in coastal altimetry on the technical side and the ensuing applications, that is, first improvements in retracking and improvements in corrections. Passaro et al. have reviewed the different approaches taken in literature for the processing of coastal pulse-limited waveforms that do not conform to the Brown model. SAR altimetry is intrinsically promising for coastal applications by virtue of the higher signal-to-noise ratio and along-track resolution. The accurate retrieval of sea surface height from satellite altimetry with centimeter-level accuracy requires the knowledge of all terms involved in the altimeter measurement system with similar or better accuracy. Those are satellite height above a reference ellipsoid from precise orbit determination; altimeter range from dedicated retracking, including all instrument effects; and all range and geophysical corrections. The corrections with particular issues in the coastal regions are mainly the wet tropospheric correction, the sea state bias, and to somewhat lesser extent the dry tropospheric correction.

Objective Diagnosing tumor progression and pseudoprogression remains challenging for many clinicians. Accurate recognition of these findings remains paramount given necessity of prompt treatment. However, no consensus has been reached on the optimal technique to discriminate tumor progression. We sought to investigate the role of magnetic resonance perfusion (MRP) to evaluate tumor progression in glioma patients. Methods An institutional retrospective review of glioma patients undergoing MRP with concurrent clinical follow up visit was performed. MRP was evaluated in its ability to predict tumor progression, defined clinically or radiographically, at concurrent clinical visit and at follow up visit. The data was then analyzed based on glioma grade and subtype. Resusts A total of 337 scans and associated clinical visits were reviewed from 64 patients. Sensitivity, specificity, positive and negative predictive value were reported for each tumor subtype and grade. The sensitivity and specificity for high-grade glioma were 60.8% and 87.8% respectively, compared to low-grade glioma which were 85.7% and 89.0% respectively. The value of MRP to assess future tumor progression within 90 days was 46.9% (sensitivity) and 85.0% (specificity). Conclusion Based on our retrospective review, we concluded that adjunct imaging modalities such as MRP are necessary to help diagnose clinical disease progression. However, there is no clear role for stand-alone surveillance MRP imaging in glioma patients especially to predict future tumor progression. It is best used as an adjunctive measure in patients in whom progression is suspected either clinically or radiographically.

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A 66-year-old female developed progressive multifocal leukoencephalopathy (PML) 17 months after treatment with bendamustine and rituximab chemoimmunotherapy. During her evaluation for PML, she was found to have a CD4 count of 176 cells/μL (reference range 492-1740). The patient demonstrated spontaneous recovery of symptoms that occurred in parallel with recovery of the CD4 counts. While PML is associated with rituximab therapy, the timing and patients' clinical course are atypical, raising the possibility of a previously unreported association with bendamustine therapy.

Object The infratentorial supracerebellar approach to the pineal region presents special challenges during patient positioning. The head must be flexed and the body positioned to allow an operative trajectory under the straight sinus. Image guidance is not useful during positioning because registration and navigation take place after the head is fixed in its final position. Therefore, a reliable method of positioning based on external, easily identifiable landmarks to estimate the surgical trajectory along the straight sinus toward the pineal region is needed. Based on observation, the authors hypothesized that a line between 2 palpable external landmarks, the inion and the bregma, often approximates the surgical trajectory along the straight sinus. They tested this hypothesis by quantifying the relationship between the straight sinus and the bregma, and describe a method for estimating the working angle during patient positioning. Methods The midsagittal, Gd-enhanced, T1-weighted MR images of 102 patients were analyzed. Demographic data and the presence or absence of tentorial pathological entities was recorded. The slant of the straight sinus was classified as common, high, or low, based on a previously described classification system. A line along the bottom of the straight sinus (that is, the straight-sinus line) was extended superiorly to its intersection with the calvaria, and the distance from this intersection point to the bregma was measured. Results The intersection point of the straight-sinus line and the calvaria was on average 2 ± 8.2 mm (these values are expressed as the mean ± SD throughout) anterior to the bregma (range 19.9 mm anterior to 19.1 mm posterior). The distance from the intersection point to the bregma was not statistically significantly different in younger or older patients, or in patients with or without tumors involving the pineal region. In patients with a low slant of the straight sinus, the intersection point was 5.3 ± 6.3 mm anterior to the bregma, whereas in patients with a high slant of the straight sinus, the intersection point was 0.21 ± 9.1 mm posterior to the bregma (p = 0.015). Conclusions The straight-sinus line, which defines the working angle for the supracerebellar infratentorial approach, intersects the calvaria very close to the bregma in the majority of patients. Therefore, ideal patient positioning can be achieved by flexing the patient's head to optimize the working angle defined by an imaginary line connecting the torcula (inion) to the bregma.

Lymphoma involving the pituitary gland is very rare and usually results from metastatic spread of systemic lymphoma. We present a case of primary central nervous system (CNS) large B cell lymphoma that manifested as pituitary apoplexy. A 45-year-old woman presented with headache, and then rapidly developed a third nerve palsy and bitemporal hemianopsia. Imaging suggested a pituitary macroadenoma, with spontaneous necrosis, extending into the suprasellar region, compressing the optic chiasm and invading the right cavernous sinus. The patient underwent transsphenoidal resection which revealed a vascular, firm tumor. An aggressive decompression of the optic chiasm was performed with complete resolution of both visual fields and third nerve palsy. Final pathology showed B cell lymphoma. Systemic work-up including bone marrow aspiration and CSF studies showed no other foci of lymphoma, and the patient was HIV-negative. Chemotherapy with methotrexate, vincristine, procarbazine, and dexamethasone was administered for primary CNS lymphoma. This is an uncommon diagnosis of which the clinician should be aware in order to tailor surgical intervention and provide early institution of proper therapy.

The Envisat RA-2 burst echoes are being gathered throughout the mission; however, these data are only now being made generally available by the European space agency. Considerable work has been necessary to turn these engineering-level data into a useable altimeter product. This paper documents the processing steps undertaken to generate usable data and presents the first extensive analysis of this unique dataset, using over 75 000 burst sequences with a global distribution. The results show that the burst echo data from Envisat are of extremely low noise, which is particularly evident over non-ocean surfaces, and contain a wealth of detailed information from both land and ocean surfaces. Examples illustrate the complexity of surface response from targets such as inland water and rough terrain. These unique data clearly have the potential to inform future instrument design as well as to improve the understanding of existing altimeter datasets.